Welcome to our second Survey Readiness newsletter. Please review the following tips and tools for a successful accreditation survey. 

One quick (and important) tip: Positively promote who you are by identifying yourself and wearing your name badge above the waist so it is visible at all times. 

It is important to recognize and respect the rights of a patient, and provide care, treatment, and services in a manner that respects and fosters the patient’s dignity, autonomy, civil rights, and involvement in his or her care. 

Care, treatment, and services are planned and provided with regard to the patient’s personal values, beliefs, and preferences. The components involved with Patient Rights and responsibilities are: 

• Developing and communicating patient rights
• Participating in care decisions
• Obtaining informed consent
• Right to know care providers
• Respecting the patient's rights, including end-of-life care
• Patient responsibilities

Items to review

• Advanced Directive: This is a legal document indicating what life-sustaining treatment is to be administered, discontinued, or withheld if an individual has lost his or her ability to make medical decisions about his or her own healthcare.
• Who is considered a legal adult? – Patients 18 years or older are legally considered adults and are expected to make their own decisions unless a legally recognized surrogate decision-maker is identified.
• It is OUR responsibility to ask all patients >18 years old if they have advanced directives.
• If a patient has an Advanced Directive, ask for a copy to place in the medical record.
• If the patient does NOT have an Advanced Directive, the patient should be offered written information about advanced directives. 

Patient and family RIGHTS are as follows.

• To be granted access to care and treatment and to refuse or accept care
• To receive and explanation of any procedures or treatment, so that you may give informed consent.
• To have pain management and participate in how pain is managed.
• To respectful care at all times without discrimination.
• To have medical record information treated as confidential
• To expect your visit will be as safe and comfortable as possible.
• To receive complete and current information about diagnosis, treatment, and proposed future health care needs in a language you can understand. 

Patient and family RESPONSIBILITIES are as follows.

• To comfort and support family members.
• To provide accurate and complete information about past and present matters related to the patient’s health.
• To bring healthcare records, identification, and insurance information, and to pay bills promptly.
• To voice concerns and changes to the healthcare team.
• To follow prescribed treatment plans and keep appointments as well as own health record.
• To treat staff and other families in a considerate, courteous, and cooperative manner.
• To work with the healthcare team to ensure the best possible treatment, rehabilitation and discharge planning. 

Please note the following questions that a surveyor may ask you related to patient rights and responsibilities. 

Have you received education on end-of-life care?

YES! Associates are required to complete modules yearly on patient rights, ethics, diversity, advanced directives, and end-of-life issues. 

How are patients informed about their rights and responsibilities?

The “Understanding Patient Rights” booklet is provided to the patient at the time of admission or outpatient visit. The “Notice of Privacy Rights” (HIPAA information) is provided to each patient at registration. Be prepared to discuss both of these with a surveyor.

Does a patient have the right to refuse treatment?

YES! Patient and family involvement in care decisions are encouraged, including the decision to refuse treatment. 

What is "informed consent?"

• Informed consent is a process that allows the patient or the patient’s legal representative full participation in decisions regarding the patient’s care, treatment, and services. 
• Informed consent can occur ONLY when the patient or the patient’s legal representative fully understands the nature of the intervention and its risk and benefits, as well as the alternatives and their risk and benefits.
• Informed consent occurs when the patient or patient’s legal representative accepts or rejects a medical intervention willingly and without coercion. 

Have you received information about patient confidentiality?

YES! Associates are required to complete a module yearly regarding HIPAA privacy and security awareness. (This is also done as part of new hire orientation.) 

What is the proper way to dispose of Protected Health Information (PHI)?

• PHI should be placed in a locked shredder receptacle in your department. PHI should NEVER be discarded in regular trash cans.
• PHI should NEVER be emailed to any email except a chcsks.org address unless encryption is in place. Contact IT if you have questions.
• Patient information should NEVER be discussed in hallways, in your home, in other public places, or with employees who are not involved in the patient’s care.  

Do your part to maintain patients' rights to privacy and confidentiality by:

• Refraining from discussing patient information publicly or at home.
• Properly disposing of PHI in appropriate receptacles.
• Covering patients during transportation (i.e., blanket on lap or gown tied up in the back)
• Knocking BEFORE entering a room and keeping doors closed during treatments (using privacy curtains as appropriate)
• Accessing patient information ONLY on a “need to know” basis (via computer, paper records, or verbal consultation). 

You should have these on your emergency badge for easy reference! Be sure you know these codes and what to do in the instances listed below.

Surveyors will observe and interview our patients. Here are some questions patients may be asked.

• What is your knowledge of your plan of care?
• Do you know how the plan of care is being implemented?
• Tell me about the quality of the services you have received/are receiving.
• Do you have and understand your advanced directive? 
• Do you know how to voice a grievance/complaint? 

The last two items on this list are inside the hospital admission packet.

Be sure to know your disinfectant dry times!

Dwell/Contact Time: Dwell time or wet time is the amount of time a disinfectant needs to sit on a surface without being wiped away or disturbed to kill germs effectively.